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Original Investigation |

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients The Transitional Care Bridge Randomized Clinical Trial

Bianca M. Buurman, RN, PhD1,2; Juliette L. Parlevliet, MD1; Heather G. Allore, PhD2,3; Willem Blok, MD, PhD4; Bob A. J. van Deelen, MD5,6; Eric P. Moll van Charante, MD, PhD7; Rob J. de Haan, RN, PhD8; Sophia E. de Rooij, MD, PhD1,9
[+] Author Affiliations
1Section of Geriatric Medicine, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
2Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
3Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
4Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
5Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
6Department of Geriatric Medicine, Kennemer Gasthuis, Haarlem, the Netherlands
7Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
8Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
9Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
JAMA Intern Med. 2016;176(3):302-309. doi:10.1001/jamainternmed.2015.8042.
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Importance  Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results.

Objective  To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone.

Design, Setting, and Participants  This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk–Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs ≥24). The dates of the analysis were June 1, 2014, to November 15, 2014.

Interventions  The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan.

Main Outcomes and Measures  The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home.

Results  The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant.

Conclusions and Relevance  A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients.

Trial Registration  Netherlands Trial Registry: NTR2384

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Figure 1.
CONSORT Diagram of Participant Inclusion

For ADL and cognition, all participants had baseline data and were included in the analyses of these outcomes. The numbers specified are those with 6-month assessment data on ADL and cognition. Nursing home discharged to community applies only for those who went directly from the hospital to a nursing home. Readmission data were only available for those who were discharged alive. ADL indicates activities of daily living; CCRN, community care registered nurse; CGA, comprehensive geriatric assessment; and CONSORT, Consolidated Standards of Reporting Trials.

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Figure 2.
Mortality From Admission to 6 Months After Admission

Shown are survival curves from a Cox proportional hazards regression analysis adjusted for study site and cognitive functioning (Mini-Mental State Examination Score, <24 vs ≥24), with the numbers of participants at risk for each 30-day interval for the intervention arm and the CGA-only arm. Significant protective intervention effects were observed for 1-month mortality and 6-month mortality. CGA indicates comprehensive geriatric assessment.

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